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Showing results for "mistakes".

  1. Leadership committed to safety. | PSNet

    psnet.ahrq.gov/issue/leadership-committed-safety
    December 23, 2016 - Sentinel Event Alerts Leadership committed to safety. Citation Text: Leadership committed to safety. Sentinel Event Alert. August 27, 2009;(43):1-3. Copy Citation Save Save to your library Print Download PDF Share Facebook Twitter …

  2. Tubing misconnections—a persistent and potentially deadly occurrence. | PSNet

    psnet.ahrq.gov/issue/tubing-misconnections-persistent-and-potentially-deadly-occurrence
    March 14, 2018 - Newspaper/Magazine Article Tubing misconnections—a persistent and potentially deadly occurrence. Citation Text: Organizations USAJC on A of H. Tubing misconnections--a persistent and potentially deadly occurrence. Sentinel event alert. 2006;(36):1-3. Copy Citation Format: G…

  3. How nursing homes’ worst offenses are hidden from the public. | PSNet

    psnet.ahrq.gov/issue/how-nursing-homes-worst-offenses-are-hidden-public
    September 22, 2021 - Newspaper/Magazine Article How nursing homes’ worst offenses are hidden from the public. Citation Text: How nursing homes’ worst offenses are hidden from the public. Gebeloff R, Thomas K, Silver-Greenberg J. New York Times. December 9, 2021. Copy Citation Save …

  4. Between a rock and a hard place: disclosing medical errors. | PSNet

    psnet.ahrq.gov/issue/between-rock-and-hard-place-disclosing-medical-errors
    October 19, 2022 - Commentary Between a rock and a hard place: disclosing medical errors. Citation Text: Crone KG, Muraski MB, Skeel JD, et al. Between a rock and a hard place: disclosing medical errors. Clin Chem. 2006;52(9):1809-14. Copy Citation Format: Google Scholar PubMed BibTeX EndNo…

  5. Total systems safety supports practitioners in partnering with families to protect patients. | PSNet

    psnet.ahrq.gov/issue/total-systems-safety-supports-practitioners-partnering-families-protect-patients
    April 17, 2024 - Newspaper/Magazine Article Total systems safety supports practitioners in partnering with families to protect patients. Citation Text: Total systems safety supports practitioners in partnering with families to protect patients. ISMP Medication Safety Alert! Acute Care. 2024;29(13):1-4. …

  6. Vermont Health Clinics Promote AHRQ’s Medication Safety Guide | Agency for Healthcare Research and Quality

    www.ahrq.gov/news/newsroom/case-studies/202003.html
    June 01, 2020 - Vermont Health Clinics Promote AHRQ’s Medication Safety Guide Search All Impact Case Studies June 2020 A Vermont-based based trio of Federally Qualified Health Centers (FQHC) has improved medication use and safety for approximately 8,000 patients by adapting an evidence-based strategy from AHRQ's Guide to …

  7. With oral chemotherapy, we simply must do better! | PSNet

    psnet.ahrq.gov/issue/oral-chemotherapy-we-simply-must-do-better
    February 13, 2019 - Newspaper/Magazine Article With oral chemotherapy, we simply must do better! Citation Text: With oral chemotherapy, we simply must do better! ISMP Medication Safety Alert! Acute Care Edition. July 17, 2014;19:1-4. Copy Citation Save Save to your library Prin…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865346/psn-pdf
    March 27, 2024 - RaDonda Vaught says some system practices contributed to fatal mistake. March 27, 2024 Clark C. MedPage Today. March 14, 2024. https://psnet.ahrq.gov/issue/vaught-says-some-system-practices-contributed-fatal-mistake Stories from clinicians involved in errors provide unique insights into both the human an…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72658/psn-pdf
    January 20, 2021 - “I made a mistake!”: a narrative analysis of experienced physicians' stories of preventable error. January 20, 2021 Kandasamy S, Vanstone M, Colvin E, et al. “I made a mistake!”: a narrative analysis of experienced physicians' stories of preventable error. J Eval Clin Pract. 2021;27(2):236-245. doi:10.1111/jep.1353…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47957/psn-pdf
    April 24, 2019 - A really stupid mistake: it does feel like a cop out to blame my error on human frailty, but I'm afraid that's exactly what it was. April 24, 2019 Maskell G. A really stupid mistake: it does feel like a cop out to blame my error on human frailty, but I'm afraid that's exactly what it was. BMJ. 2019;365:l1617. doi:…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38894/psn-pdf
    August 26, 2009 - Negotiating medical virtues: toward the development of a physician mistake disclosure model. August 26, 2009 Hannawa AF. Negotiating medical virtues: toward the development of a physician mistake disclosure model. Health Comm. 2009;24(5):391-399. doi:10.1080/10410230903023279. https://psnet.ahrq.gov/issue/negotiat…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39296/psn-pdf
    January 22, 2017 - Applying Lean Sigma solutions to mistake-proof the chemotherapy preparation process. January 22, 2017 Aboumatar HJ, Winner L, Davis RO, et al. Applying Lean Sigma solutions to mistake-proof the chemotherapy preparation process. Jt Comm J Qual Patient Saf. 2010;36(2):79-86. https://psnet.ahrq.gov/issue/applying-lea…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39964/psn-pdf
    January 04, 2011 - Fatal consequences of a simple mistake: how can a patient be saved from inadvertent intrathecal vincristine? January 4, 2011 Reddy K, Brown B, Nanda A. Fatal consequences of a simple mistake: how can a patient be saved from inadvertent intrathecal vincristine? Clin Neurol Neurosurg. 2011;113(1):68-71. doi:10.1016/…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46037/psn-pdf
    April 16, 2018 - 'If no-one stops me, I'll make the mistake again': changing prescribing behaviours through feedback; a Perceptual Control Theory perspective. April 16, 2018 Ferguson J, Keyworth C, Tully MP. 'If no-one stops me, I'll make the mistake again': Changing prescribing behaviours through feedback; A Perceptual Control Th…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39241/psn-pdf
    March 05, 2010 - Dealing honestly with an honest mistake. March 5, 2010 Liang NL, Herring ME, Bush RL. Dealing honestly with an honest mistake. J Vasc Surg. 2010;51(2):494-5. doi:10.1016/j.jvs.2009.11.001. https://psnet.ahrq.gov/issue/dealing-honestly-honest-mistake This case report describes a near miss involving a potential hepa…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39771/psn-pdf
    August 18, 2010 - Bearing witness to the ethics of practice: storying physicians' medical mistake narratives. August 18, 2010 Carmack HJ. Bearing witness to the ethics of practice: storying physicians' medical mistake narratives. Health Commun. 2010;25(5):449-58. doi:10.1080/10410236.2010.484876. https://psnet.ahrq.gov/issue/bearin…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37148/psn-pdf
    March 11, 2009 - CMS: your mistake, your problem. March 11, 2009 Lubell J. CMS: your mistake, your problem. Eight hospital-acquired conditions won't be paid for. Modern healthcare. 2007;37(33):10-1. https://psnet.ahrq.gov/issue/cms-your-mistake-your-problem This article discusses the challenges hospitals face in responding to rece…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37044/psn-pdf
    September 05, 2007 - Make no mistake about it: chain pharmacies are finding innovative ways to combat medication errors. September 5, 2007 Levy S. Drug Topics. July 9, 2007 https://psnet.ahrq.gov/issue/make-no-mistake-about-it-chain-pharmacies-are-finding-innovative-ways- combat-medication This article reports on ways in which chain …

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42753/psn-pdf
    November 20, 2013 - Dealing with a medical mistake: should physicians apologize to patients? November 20, 2013 Tabler NG Jr. https://psnet.ahrq.gov/issue/dealing-medical-mistake-should-physicians-apologize-patients This article discusses how apologies address patients' needs when a medical mistake has occurred and how such disclosur…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39344/psn-pdf
    March 03, 2010 - Mistake-proofing healthcare: why stopping processes may be a good start. March 3, 2010 Grout JR, Toussaint JS. Mistake-proofing healthcare: Why stopping processes may be a good start. Bus Horiz. 2009;53(2):149-156. doi:10.1016/j.bushor.2009.10.007. https://psnet.ahrq.gov/issue/mistake-proofing-healthcare-why-stopp…
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